Original Research
Blood Pressure Management in Adults With Type 2 Diabetes: Insights From the Diabetes Mellitus Status in Canada (DM-SCAN) Survey

https://doi.org/10.1016/j.jcjd.2017.01.005Get rights and content

Abstract

Objectives

Optimal treatment of blood pressure (BP) and other cardiovascular risk factors, including hyperglycemia, is integral to diabetes management. There are limited data from the primary care setting concerning the contemporary and comprehensive management of type 2 diabetes and other cardiovascular risk factors in relation to guideline-recommended BP target achievement.

Methods

The Diabetes Mellitus Status in Canada (DM-SCAN) survey included 5172 ambulatory patients with type 2 diabetes. Data were collected on patient demographics, medical histories, medication usage, BP levels and laboratory investigations. We stratified the study population based on their attainment of the BP target recommended by the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and the Canadian Hypertension Education Program (<130/80 mmHg) and compared patient clinical characteristics and treatments.

Results

Of the 5145 patients with available BP data, 36% achieved the BP target. Prevalence of smoking, known coronary artery disease, retinopathy, neuropathy and nephropathy were similar in the groups with BP 130/80 mmHg or higher and BP 130/80 mmHg or lower. Patients with BP 130/80 mmHg or higher were taking more antihypertensive agents and were more likely to be taking angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, diuretics and calcium channel blockers. They also had significantly higher glycated hemoglobin and low-density lipoprotein-cholesterol levels. Overall, these patients were also less likely to achieve guideline-recommended glycemic and lipid targets.

Conclusions

Only about one-third of patients with diabetes achieved the target BP of below 130/80 mmHg. Patients with BP 130/80 mmHg or higher were also less likely to achieve optimal guideline-recommended glycated hemoglobin and low-density lipoprotein-cholesterol targets. Improved comprehensive management of all risk factors in patients with diabetes is warranted.

Résumé

Objectifs

Le traitement optimal de l'hypertension artérielle et d'autres facteurs de risque cardiovasculaire, y compris l'hyperglycémie, fait partie intégrante de la prise en charge du diabète. Il y a peu de données en soins primaires sur la prise en charge contemporaine et globale du diabète de type 2 et d'autres facteurs de risque cardiovasculaire par rapport à l'atteinte des cibles tensionnelles recommandées dans les lignes directrices.

Méthodologie

Le programme DM-SCAN (Diabetes Mellitus Status in Canada) regroupait 5172 patients ambulatoires présentant un diabète de type 2. Des données sur les caractéristiques démographiques, les antécédents médicaux, l'utilisation de médicaments et les valeurs tensionnelles et biochimiques des patients ont été recueillies. Nous avons stratifié la population à l'étude en fonction de l'atteinte des cibles tensionnelles recommandées dans les lignes directrices de l'Association canadienne du diabète et dans le cadre du Programme éducatif canadien sur l'hypertension (<130/80 mmHg) et comparé les caractéristiques cliniques et les traitements au sein de cette population.

Résultats

Trente-six pour cent des 5145 patients dont les valeurs tensionnelles étaient documentées avaient atteint les cibles tensionnelles. La prévalence du tabagisme et des cas connus de coronaropathie, de rétinopathie, de neuropathie et de néphropathie était comparable dans les groupes présentant des valeurs tensionnelles de 130/80 mmHg ou plus et de 130/80 mmHg ou moins. Les patients présentant des valeurs tensionnelles de 130/80 mmHg ou plus prenaient plus d'antihypertenseurs et étaient davantage susceptibles de prendre des inhibiteurs de l'enzyme de conversion de l'angiotensine et/ou des inhibiteurs des récepteurs de l'angiotensine, des diurétiques et des inhibiteurs calciques. Ils présentaient aussi des taux d'hémoglobine glyquée et de cholestérol à lipoprotéines de faible densité significativement plus élevés. Dans l'ensemble, ces patients étaient également moins susceptibles d'atteindre les cibles glycémiques et lipidiques recommandées dans les lignes directrices.

Conclusions

Environ le tiers seulement des patients diabétiques avaient atteint les cibles tensionnelles inférieures à 130/80 mmHg. Les patients présentant des valeurs tensionnelles de 130/80 mmHg ou plus étaient également moins susceptibles d'atteindre les taux cibles optimaux d'hémoglobine glyquée et de cholestérol à lipoprotéines de faible densité recommandés dans les lignes directrices. Une meilleure prise en charge globale de tous les facteurs de risque est nécessaire chez les patients diabétiques.

Introduction

Type 2 diabetes is a significant cause of morbidity and mortality in Canada and worldwide (1). The benefits of blood pressure (BP) control in patients with type 2 diabetes on cardiovascular outcomes and complications resulting from diabetes are well established, although there remain significant variations in recommendations and practices.

Data from early trials of BP lowering in patients with diabetes showed mortality benefit, reduction in cerebrovascular events and reduction in microvascular complications caused by diabetes (2). Several large-scale studies and systematic reviews have confirmed that antihypertensive therapy is highly effective in reducing death and morbidity resulting from type 2 diabetes and its complications 3, 4, 5, 6.

Despite extensive data regarding the effects of BP management on end-organ damage and cardiovascular outcomes, the optimal target BP levels are still under debate, and there is heterogeneity in guidelines worldwide. Current The Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and the Canadian Hypertension Education Panel (CHEP) guidelines have continued to recommend targeting BP to 130/80 mmHg or lower 7, 8 while also emphasizing glycemic control and a multifactorial cardiovascular risk-factor management strategy. Overall, there are limited contemporary data concerning whether current Canadian Diabetes Association (now Diabetes Canada)/CHEP-recommended BP targets translate into practice and how patients differ in relation to their achieved BP levels.

The Diabetes Mellitus Status in Canada (DM-SCAN) survey was conducted to obtain point-prevalence data about patients with diabetes who are managed in the community in Canada, and the overall results have been published (9). This cross-sectional study aims to compare the demographics, clinical features and management strategies in relation to achievement of target BP levels below 130/80 mmHg in order to attain better understanding of the barriers to target BP achievement in Canadian patients with diabetes who are managed in the primary care setting.

Section snippets

Study design

Data were obtained from the DM-SCAN survey, the study design of which has been detailed in prior publications 9, 10. Briefly, the Canadian Heart Research Centre invited primary care physicians (PCPs) across Canada, between September and December 2012, to complete a 10-question survey collecting information regarding their practices and patients with type 2 diabetes. Physicians who completed the initial survey were then asked to participate in the DM-SCAN survey by filling out an anonymous

Patient demographics

From the original 738 PCPs who completed the initial audit form, 479 participated in the study (65% participation rate) and provided data for a total of 5172 patients with type 2 diabetes who were cared for in their practices. There was physician and patient representation from all provinces, although 56% of the physicians were based in Ontario. Physicians were recruited from varied practice settings, with 16% located in inner-city settings, 63% in urban or suburban settings and 21% in

Discussion

This cross-sectional study demonstrates that patients with type 2 diabetes who failed to meet the CDA/CHEP-recommended BP target were also less likely to achieve other guideline-recommended targets, namely LDL-C and A1C goals. The prevalence of microvascular and macrovascular complications of diabetes did not differ in relation to achieved BP levels. Patients who did not achieve the BP target were prescribed a greater number of antihypertensive medications than their counterparts who achieved

Conclusions

Patients with type 2 diabetes who did not achieve recommended BP levels were more likely to be taking a greater number of antihypertensive agents. Furthermore, they were less likely to have been prescribed statins, despite being more likely to have higher LDL-C levels and to have higher A1C levels than their counterparts. Achievement of all guideline-recommended targets was less prevalent in patients with higher BP and was low in both groups overall. This demonstrates ongoing care gaps in the

Conflict of interest

Jasmine Grenier: None

Shaun G. Goodman: Speaker, consulting honoraria, and/or research grant support from Sanofi, Bristol Myers Squibb

Lawrence A. Leiter: Speaker, consulting honoraria, and/or research grant support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmith Kline, Janssen, Merck, Novartis, Novo Nordisk, Sanofi, Servier and Takeda

Anatoly Langer: Speaker, consulting honoraria, and/or research grant support from Merck

Kim A. Connelly: Speaker,

Role of the funding source

The Diabetes Mellitus Status in Canada (DM-SCAN) survey was made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc. The Canadian Heart Research Centre developed the protocol, coordinated the study, collected and managed the data.

Acknowledgements

The DM-SCAN survey was made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc. The Canadian Heart Research Centre developed the protocol, coordinated the study and collected and managed the data. We thank Sue Francis, BA, for her editorial assistance in the preparation of this manuscript. Dr. Shaun Goodman is supported by the Heart and Stroke Foundation of Ontario in his

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    The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.

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